Background
Methods
Design
Population
Syncope guidelines intervention
ESC Syncope Guidelines implementation
Quick referral routes to a syncope unit
Reference standard
Classification of the treating physician’s diagnosis
Treating physician’s conclusion | Criteria to evaluate concordance of the management plan with the suggested condition | |||
---|---|---|---|---|
Admission | Follow-up | Investigations following ED visit | Treatment | |
Reflex syncope (including vasovagal syncope, carotid sinus syndrome and situational syncope) | No admission except for underlying cause (e.g. gastroenteritis) or trauma due to syncope | No referral to outpatient clinic, except for syncope unit | No investigations except for tilt test (optional) | Optional: Education in counter pressure manoeuvres Treatment with drugs that may prevent reflex syncope (e.g. midodrine) |
Orthostatic hypotension (including initial, classic and delayed orthostatic hypotension) | No admission except for underlying cause (e.g. dehydration, bleeding) | Optional: Referral to GP or outpatient clinic for analysis of underlying cause | Optional: Tilt table testing, active standing test, autonomic function test, work-up to identify underlying neurological cause (e.g. polyneuropathy) | Optional: Treatment of underlying cause (e.g. rehydration) Deprescribing of blood pressure-lowering drugs Prescription of blood pressure-increasing drugs Education in counter-pressure manoeuvres |
Cardiac syncope Cardiopulmonary and great vessels | Admission to cardiology department* except when treatment did not necessitate admission Admission if needed | Follow-up cardiology department to confirm diagnosis or evaluate treatment Follow-up pulmonologist, vascular surgeon | Optional: Monitoring heart rhythm (in-hospital, Holter ECG) Echocardiography Exercise testing Implantation of cardiac monitoring devices Imaging aorta/pulmonary veins | Optional: Implantation of pacemaker/defibrillator Surgical intervention for structural causes Prescription of anti-arrhythmical drugs Optional: Anti-thrombotic therapy Surgical intervention |
Epileptic seizure | Optional: Admission to neurology department | Referral to neurology outpatient clinic except for provoked seizures | Optional: MRI, CT brain or EEG | Optional: Prescription of anti-seizure medication |
Psychogenic TLOC | No admission except for injuries due to TLOC necessitating admission | Variable (no follow-up, referral to GP, consultation psychiatrist or psychologist) | None | Education or treatment plan as defined by psychiatrist, psychologist or GP |
Diagnostic accuracy
Syncope-related healthcare and societal costs
Sample size
Statistical analysis
Results
Study population
Usual care, n = 275 | Syncope guidelines, n = 246 | p-value | Missing data | |
---|---|---|---|---|
Age, years (mean, SD) | 63 ± 17 | 64 ± 16 | 0.44 | None |
18–35 years | 24 (8.7%) | 15 (6.1%) | ||
36–50 years | 35 (13%) | 32 (13%) | ||
51–74 years | 139 (51%) | 129 (52%) | ||
> 75 years | 77 (28%) | 70 (29%) | ||
Sex | 0.68 | None | ||
Male | 157 (57%) | 136 (55%) | ||
Female | 118 (43%) | 110 (45%) | ||
Centre | 0.23 | None | ||
Leiden | 40 (15%) | 50 (20%) | ||
Utrecht | 56 (20%) | 55 (22%) | ||
Arnhem | 48 (18%) | 39 (16%) | ||
Rotterdam | 61 (22%) | 56 (23%) | ||
Apeldoorn | 70 (26%) | 46 (19%) | ||
Diagnosis according to the reference standard | 0.19 | None | ||
Syncope due to reflex syncope or OH | 198 (72%) | 193 (79%) | ||
Cardiac syncope | 26 (9.5%) | 25 (10%) | ||
Epileptic seizure | 9 (3.3%) | 5 (2.0%) | ||
Psychogenic TLOC | 5 (1.8) | 1 (0.4%) | ||
Unknown aetiology | 37 (14%) | 22 (8.9%) | ||
Time of ED visit | 0.36 | None | ||
12 am–6 am | 21 (7.6%) | 26 (11%) | ||
6 am–12 pm | 88 (32%) | 65 (26%) | ||
12 pm–6 pm | 111 (40%) | 99 (40%) | ||
6 pm–12 am | 54 (20%) | 56 (23%) | ||
Referral pathway | 0.90 | None | ||
Self-referral | 15 (5.5%) | 10 (4.1%) | ||
GP referral | 53 (19%) | 50 (20%) | ||
Ambulance | 183 (67%) | 164 (67%) | ||
Not documented | 24 (8.7%) | 22 (8.9%) | ||
Manchester Scale Triage code | 0.44 | None | ||
Red | – | 1 (0.4%) | ||
Orange | 20 (7.3%) | 16 (6.5%) | ||
Yellow | 165 (60%) | 152(62%) | ||
Green | 47 (17%) | 31(13%) | ||
Unknown | 43 (16%) | 46 (19%) | ||
Family history of sudden cardiac death (< 60 years) | 0.25 | None | ||
Presence or absence mentioned | 38 (14%) | 43 (17%) | ||
Presence or absence not mentioned | 237 (86%) | 203 (83%) | ||
Posture prior to TLOC | 0.88 | None | ||
Mentioned | 238 (87%) | 214 (87%) | ||
Not mentioned | 37 (14%) | 32 (13%) | ||
Confusion afterwards | 0.16 | None | ||
Presence or absence mentioned | 200 (73%) | 192 (78%) | ||
Presence or absence not mentioned | 75 (27%) | 54 (22%) | ||
Tongue bite | 0.45 | None | ||
Presence or absence mentioned | 200 (73%) | 186 (76%) | ||
Presence or absence not mentioned | 75 (27%) | 60 (24%) | ||
Prodromes | 1.00 | None | ||
Presence or absence mentioned | 275 (100%) | 246 (100%) | ||
Presence or absence not mentioned | – | – | ||
Circumstances related to TLOC | 0.41 | None | ||
Mentioned | 257 (94%) | 234 (95%) | ||
Not mentioned | 18 (6.5%) | 12 (4.9%) | ||
ECG in the ED | 0.20 | None | ||
Recorded | 254 (92%) | 234 (95%) | ||
Not recorded | 21 (7.6%) | 12 (4.9%) | ||
Holter ECG | ||||
Recorded | 28 (10%) | 23 (9.3%) | 0.75 | |
Not recorded | 247 (90%) | 223 (91%) | ||
OH screening (standing test) in the ED | < 0.01 | None | ||
Performed | 45 (16%) | 64 (26%) | ||
Not performed | 230 (84%) | 182 (74%) | ||
No. of consultations in the ED | 0.30 | None | ||
One | 131 (48%) | 121 (50%) | ||
Two | 101 (37%) | 74 (30%) | ||
Three | 34 (12%) | 40 (16%) | ||
Four | 9 (3.3%) | 11 (4.5%) | ||
Hospital admission following ED visit | 146 (53%) | 106 (43%) | 0.02 | None |
With telemetry | 110 (40%) | 87 (35%) | ||
Without telemetry | 36 (13%) | 19 (7.7%) | ||
Hospital admissions following ED visit among those with exclusively low-risk criteria | ||||
Yes | 84 (43.1%) | 66 (34%) | 0.07 | None |
No | 111 (57%) | 127 (66%) | ||
Syncope unit referral | – | 37 (15%) | Not performed | None |
Tilt testing | 5 (1.8%) | 17 (6.9%) | < 0.01 | None |
Implantation loop recorder | 10 (3.6%) | 13 (5.3%) | 0.36 | None |
QALY for the study period (EQ5D) | 0.81 | 0.79 | 0.50 | UC 104 (37%) |
SG 113 (46%) |
Diagnostic performance
Ancillary testing
Healthcare and societal costs
Usual care (n = 275) | Syncope guidelines (n = 246) | Difference | ||||
---|---|---|---|---|---|---|
Number per patient | Costs per patient | Number per patient | Costs per patient | Costs per patient | p-value | |
Hospital admissions (days) | ||||||
Following the initial ED visit* | 1.36 | 727 | 1.11 | 591 | − 136 | 0.23 |
Later | 0.91 | 485 | 0.74 | 397 | − 88 | 0.47 |
Later ED visits | 0.16 | 45 | 0.15 | 44 | − 1 | 0.96 |
Hospital diagnostic procedures | 3.35 | 583 | 3.08 | 536 | − 47 | 0.70 |
Outpatient hospital visits | 0.88 | 94 | 0.72 | 78 | − 16 | 0.23 |
Hospital treatments | 0.25 | 409 | 0.18 | 323 | − 86 | 0.64 |
GP visits | 0.71 | 29 | 0.96 | 39 | 10 | 0.13 |
GP diagnostic procedures | 0.38 | 21 | 0.46 | 27 | 6 | 0.56 |
Total healthcare costs (SD) | 2393 (3844) | 2035 (3353) | − 358 | 0.27 | ||
Absenteeism (days) | 5.39 | 1152 | 2.62 | 602 | − 550 | 0.06 |
Total societal costs (SD) | 3545 (5170) | 2637 (4109) | − 908 | 0.04 |